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Patient Information (required)

Birthdate (required)

Gender (required)

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Address

Address

Email (required)

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Phone Number (required)

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Phone

Responsible Party (required)

Address

Address

Cell Phone

Phone

Emergency Contact (required)

Medical Insurance

Dental Insurance

Birth Date

ID

Secondary INS Company

Birth Date

ID

Assignment and release: I understand that I am responsible for payment of services rendered and for paying any co-payment and deductible that my insurance does not cover. I certify that I/ my dependents are covered by the above named insurance. I hereby authorize the release of any information necessary to my insurance company to secure payments of benefits. I authorize the use of this signature on all insurance submissions whether manual or electronic.Check box and sign below.

Responsible Party Signature (required)

Date (required)